Health inspection·February 21, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the formulated advance directive for one of 12 final sampled residents (Resident 17) was accurately maintained. Resident 17 had a formulated advance directive; however, Resident 17's POLST failed to show Resident 17 had formulated an advance directive. This failure posed the risk of the resident not receiving appropriate interventions as the medical record information was inaccurate and the residents' decision regarding their health care and treatment options to not be honored. Findings: Medical record review for Resident 17 was initiated on 2/14/23. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's POLST, Section D (advance directive) dated 5/6/21, failed to show documentation Resident 17 had formulated an advance directive. Review of Resident 17's History and Physical Examination dated 2/14/23, showed Resident 17 had the capacity to understand and make decisions. Review of the MDS dated [DATE], showed Resident 17 was cognitively intact. Review of Resident 17's Advance Healthcare Directive Form dated 11/7/22, showed Resident 17 had formulated an advance directive. Further review of Resident 17's medical record failed to show the resident's POLST was updated to show an advance directive was formulated. On 2/14/23 at 1450 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 17 had formulated an advance directive, but the POLST was not updated to show an advance directive was formulated. RN 2 stated the advance directive should have been clarified with the resident and Ombudsman. Page 1 of 29 555709 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident-centered care plan was developed for one of 12 sampled residents (Resident 14). This failure posed the risk for not providing necessary care and services for the resident. Findings: Review of the facility's P&P titled Seizure Precautions revised and reviewed by the facility on 6/2020 showed in part, the following: Purpose: A. To prevent injury to the patient during the seizure. Equipment: A. Side rails are to be padded with bath blankets or anti-trauma pads. Policy: The procedure is to be started on all patients with a diagnosis or history of seizure activity. Procedure: A. Nursing responsibility for seizure precautions: 1. Side rails (padded) up at all times. Review of Resident 14's medical record was initiated on 2/14/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's H&P Examination dated 7/21/22, showed a diagnosis of seizure disorder. Review of Resident 14's MDS dated [DATE], showed the resident's diagnoses included seizure disorder and traumatic brain injury On 2/14/23 at 1448 hours, an observation of Resident 14 was conducted. Resident 14 was observed laying on his back in bed. The side rails of Resident 14's bed did not have padding of any kind on the side rails. On 2/15/23 at 1059 hours, an observation of Resident 14 and concurrent interview was conducted with LVN 1. Resident 14 was observed laying on his back in bed. The side rails of Resident 14's bed did not have padding of any kind on the side rails. LVN 1 verified the above findings. When asked if Resident 14's bed should have padded side rails, LVN further verified the side rails of Resident 14's bed should have had padding to prevent injury. 555709 Page 2 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0656 Level of Harm - Minimal harm or potential for actual harm On 2/15/23 at 1125 hours, Resident 14's medical record review was conducted with the DSD. When asked who was responsible for formulating Resident 14's plan of care, the DSD stated it was the charge nurse's responsibility on admission. When asked why it was important Resident 14 had a care plan which included padded side rails, the DSD answered it was important for every staff to know what was going on with Resident 14 and if Resident 14 had seizures, so the staff could keep Resident 14 safe. Residents Affected - Few On 2/15/23 at 1132 hours, a review of Resident 14's medical record was conducted with the DSD. When asked if Resident 14 had any care plans in the paper chart or electronic chart for the staff to be aware that they needed to pad Resident 14's bed side rails to prevent injury due to seizure, the DSD answered no. On 2/16/23 at 1148 hours, an observation of Resident 14 was conducted with RN 1. Resident 14 was observed laying on his back in bed. Resident 14's bed side rails were observed without padding of any kind on the side rails. RN 1 verified the above findings. RN 1 further verified the side rails of Resident 14's bed should have had padding to prevent injury and did not. Cross reference to F773. 555709 Page 3 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 12 final sampled residents (Resident 7) received treatment and care in accordance with the professional standards of practice. Residents Affected - Few * The facility failed to ensure Resident 7' s left foot wounds were assessed accurately. This had the potential for Resident 7 to receive the wrong treatment for his wounds. Findings: On 2/14/23 at 0841 hours, an observation and concurrent interview was conducted with LVN 6. Resident 7 was observed with a dressing to his left toes. LVN 6 was asked what type of wound Resident 7 had on his toes. LVN 6 stated Resident 7 had healing vascular ulcers (wounds on the skin that develop because of problems with blood circulation) on his toes. Medical record review for Resident 7 was initiated on 2/14/23. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Long History and Physical examination dated 11/14/22, showed Resident 7 had diagnoses that included vascular insufficiency (occurs when your leg veins do not allow blood to flow back up to your heart). Review of Resident 7's Medication Administration Record dated 2/15/23, showed the physician's orders to provide the following wound care treatments: - cleanse the left fifth toes vascular ulcer with normal saline (a mixture of sodium chloride and water), pat dry, and paint with povidone-iodine solution (an antiseptic used for skin disinfection), cover with dry dressing daily and as needed if soaked or peeled off for 21 days the reevaluate; and, - cleanse the left great toe vascular ulcer with normal saline, pat dry, paint with povidone-iodine solution, cover with a dry dressing, and wrap with a Kerlix dressing (type of wound dressing) daily and as needed if soaked or peeled off for 21 days then reevaluate. Review of Resident 7's plan of care showed a care plan problem addressing the left great toes vascular ulcer and fifth toe vascular ulcer initiated on 2/2/23, included interventions to assess the skin condition daily, inform the physician and family if any changes, and monitor for any skin breakdown. Review of Resident 7's Podiatry (a branch of medicine devoted to the study, diagnosis, medical and surgical treatment of disorders of the foot, ankle and structures of the leg) note dated 2/1/23, did not show Resident 7 had vascular ulcers on his left toes. On 2/15/23 at 1010 hours, a wound care observation and concurrent interview was conducted with LVN 1. LVN 1 was observed providing the wound care treatment as ordered by the physician. However, when asked, LVN 1 stated she did not identify any vascular ulcers on Resident 7's left great toe and fifth toe. LVN 1 stated Resident 7 did not have vascular ulcers to begin with. LVN 1 added Resident 7 555709 Page 4 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had his toenails trimmed by the podiatrist on 2/1/23, and the toes were bleeding after the treatment, and that was how Resident 7 got the wounds. LVN 1 was asked if she clarified with Resident 7's physician about the wound care treatment orders for Resident 7's vascular ulcers despite having no vascular ulcers. LVN 1 stated the facility had not done so. On 2/16/23 at 0851 hours, an interview and concurrent medical record review was conducted with RN 1 and the DON. Review of Resident 7's wound picture of the left toes taken on 2/2/23, showed dry scabs around the nail beds and no vascular ulcers were seen. The DON confirmed Resident 7's skin assessment performed on 2/2/23, and wound care treatment orders did not reflect Resident 7's actual skin condition. The DON stated they would consult with the nurse practitioner to follow up with the correct assessment, diagnosis, and wound care orders. 555709 Page 5 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review was initiated for Resident 12 on 2/13/22. Resident 12 was admitted to the facility on [DATE]. Residents Affected - Some Review of Resident 12's Daily Assessment Inquiry dated 11/18/22, showed the resident had the following wounds: - Stage 4 right ischium pressure injury with red wound bed with yellow/tan slough, moderate serous drainage, and surrounding fragile scar tissue. - Stage 4 left ischium pressure injury with red wound bed, moderate serous drainage, and surrounding fragile periwound. Review of Resident 12's Daily Assessment Inquiry dated 12/16/22, showed the following wounds: - Stage 4 right ischium pressure injury, measuring 5.1 cm x 4.7 cm x 4 cm, with undermining 2 cm from 10-3 o'clock, and tunneling of 4.8 cm at 12 o' clock; The wound had red wound bed with yellow/tan slough which decreased at the deepest part of wound, small amount of serous drainage, mild excoriation to the periwound, and excoriated surrounding tissue. - Stage 4 left ischium pressure injury, measuring 3.2 cm x 3 cm x 4 cm, with undermining 3 cm from 8-5 o'clock and tunneling of 4.2 cm at 12 o'clock. The wound had red wound bed, drainage small serous, and excoriated surrounding tissue. Review of Resident 12's Medication Order Report dated 12/9/22, showed the following physician's orders: - an order dated 8/16/22, to cleanse the right buttock fold with normal saline, pat dry, apply collagenase ointment to wound bed and calcium alginate dressing, apply calazime skin barrier to periowund, and cover with a foam dressing daily and as needed if soiled or dislodged. In addition, the order showed to apply calazime skin barrier to the right hip area every shift for skin maintenance - an order dated 12/9/22, to cleanse the right and left ischium wounds with normal saline, pat dry, apply Medihoney and collagen powder, and pack lightly with a wet to dry dressing, and cover with a dry dressing daily and as needed if soiled or dislodged. On 2/14/23 at 1350 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked about the resident's weekly assessments after 12/16/22. The DON stated they did not have the weekly assessments after 12/16/22. The treatment nurse had performed the weekly assessment but was no longer around since December 2022. The DON stated the weekly assessments for pressure injury should have been done every week. The DON verified the staff failed to do the weekly assessments after 12/16/22, for Resident 12. On 2/15/23 at 0945 hours, Resident 12's buttock area was observed to have small soft bowel movement. LVN 5 with the help of CNAs 3 and 4 were observed turning Resident 12 to his right side. LVN 5 started to do wound treatment for the resident's left ischium wound. LVN 5 removed the old dressing, washed her hands, and applied new gloves, cleansed the wound with normal saline, pat dry, apply Medihoney, collagen powder and pack lightly with wet to dry dressing 4 x 4 gauze, cover with dry dressing. 555709 Page 6 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Then Resident 12 was turned to his left side. Resident 12's new dressing to the left ischium was observed smeared with bowel movement after the resident was turning. Then LVN 5 was observed continue to complete dressing care to the right ischium wound. Neither LVN 5 or CNAs 3 or 4 cleaned the bowel movement after finished the dressing changes. LVN 5 and CNA 3 stated they were finished with the treatment. LVN 5 and CNA 3 was informed of the observation that they did not clean Resident 12's bowel movement before performing the wound treatments to the resident's wounds. LVN 5 acknowledged the bowel movement should be cleaned before starting the wound treatment so it would not contaminate the new dressing. LVN 5 verified the finding. Review of the Daily Assessment Inquiry dated 2/15/23, showed the following: - Stage 4 right ischium pressure injury, measuring 3 cm x 3.5 cm x 2.5 cm, with undermining/ tunneling as follows: 5 cm at 12 o'clock, 5.2 cm at 1 o'clock, 4.4 cm at 2 o'clock, 0.8 cm at 4 o'clock, 0.8 cm at 5 o'clock, 2.3 cm at 9 o'clock, 3.8 cm at 10 o'clock, and 4.8 cm at 11 o'clock. The wound had no drainage. - Stage 4 left ischium pressure injury, measuring 2.5 cm x 3 cm x 0.51 cm, with undermining tunneling as follows: 3 cm at 12 o'clock, 3 cm at 1 o'clock, 3 cm at 2 o'clock, 4 cm at 3 o'clock, 3 cm at 5 o'clock, and 1.8 cm at 11 o'clock. The wound had small amount of drainage small, pink and yellow/tan (slough) wound bed, and excoriated surrounding tissue. On 2/16/23 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated they had initiated the weekly assessment yesterday afternoon on 2/15/23, for all residents who had pressure ulcers with no weekly assessments. 3. Review of the facility's P&P titled Pressure Ulcer Prevention, Management Protocol & Treatment revised 10/21 showed in part: Purpose: I. To provide guidelines for assessment, staging, interventions and Documentation of patients with actual or potential [NAME] breakdown. Documentation: A. Staff are to complete a pressure ulcer assessment on admission and/or discovery, re-assessment every even (7) days. Staff are to complete care plan on admission upon discovery or with change in staging B. Photograph pressure ulcer on discovery, and significant changes. Place photos on the progress notes and label with the following: 1. Patient Name 2. Date Taken 3. Location of pressure ulcer. a. Review of Resident 3's medical record was initiated on 02/13/23. Resident 3 was admitted to the 555709 Page 7 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0686 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE], under Section M: Titled Skin Condition, showed Resident 3 was assessed with a Stage 3 pressure injury. Residents Affected - Some On 2/16/23 at 1044 hours, an interview and concurrent medical record review of Resident 3 was conducted with RN 1. When asked what date Resident 3's right buttock pressure injury was first developed, RN 1 stated in 9/22 according to the pictures. When asked how often the wound assessment and pictures were to be documented, RN 1 stated they were to be documented weekly. When asked why the weekly wound documentation and photos were important, RN 1 stated so the staff would know if a wound was getting better or getting worse. When asked where the weekly wound assessments were to be documented, RN 1 stated the assessments were to be documented in the weekly wound assessment, under the section titled Daily Wound Assessments. Review of Resident 3's weekly wound pictures showed the weekly wound photos of Resident 3's left buttock wound were not done weekly between the dates of 11/23/22 - 2/2/23. RN 1 verified the above findings. RN 1 further verified there should have been wound pictures and wound assessments weekly. However, there were not. b. Review of Resident 10's medical record was initiated on 02/14/23. Resident 10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], under section M: Titled Skin Condition, showed Resident 10 was assessed with a Stage 2 pressure injury. Review of the facility's matrix dated 2/13/23, showed Resident 10 was identified by the facility as having a facility acquired pressure injury. On 2/16/23 at 1117 hours, an interview and concurrent medical record review of Resident 10 was conducted with RN 1. When asked what date Resident 10's right buttock pressure injury was first developed, RN 1 stated on 9/8/22, according to the pictures. Review of the weekly wound photos for Resident 10 showed no weekly wound photos of the left buttock wound between 12/8/22 - 2/2/23. Review of the weekly wound assessments showed no documented evidence of the weekly assessments as follows: - Weekly wound assessments between 11/2/22 - 11/16/22 - Weekly wound assessments between 11/16/22 - 12/8/22 - Weekly wound assessments between 12/822 - 2/15/23 RN 1 verified the above weekly wound assessments were missing and should not have been. When asked why documenting the wound assessment weekly was important, RN 1 stated to keep track of the wound to make sure it did not get worse. 2. Review of the facility's P&P titled Pressure Ulcer Prevention, Management Protocol and Treatment revised 10/2021 showed the facility is to complete Pressure Ulcer Assessment on admission and/or discovery, reassessment every 7 days and at discharge. 555709 Page 8 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/15/23 at 1124 hours, a wound treatment observation was conducted for Resident 18's Stage 4 sacrococcyx pressure injury. LVN 4 applied Medihoney 80% gel to the six o'clock and nine o'clock of the wound bed. The wound bed was noted as beefy red with no odor, drainage, or slough. The wound measured 7 cm x 8.3 cm x 2.5 cm, with 3 cm tunneling and had eschar at 9 o'clock and 11 o'clock. On 2/15/23 at 1440 hours, medical record review for Resident 18 showed the resident was admitted to the facility on [DATE]. Review of the care plan problem addressing the left to right sacrococcyx wounds dated 6/3/21, showed an approach with the start date of 8/24/22, to perform skin treatment as ordered. Review of the treatment orders showed to apply Medihoney 80% gel to affect area to sacrococcyx wound extending to the left and right buttocks. * However, during the above observation, LVN 4 failed to apply the Medihoney as ordered. In addition, review of the weekly skin assessments showed the weekly skin assessments were only completed on 12/16, 12/23, and 1/20/23, instead of weekly. Review of the weekly skin assessment dated on 1/20/23, showed the wound measurements were 7.2 cm x 8.1 cm x 2.4 cm, with 3.5 cm tunneling. During an interview with LVN 4 on 2/15/23 at 1210 hours, LVN 4 verified she missed applying Medihoney 80% gel to parts of the affected areas of the wound bed. LVN 4 stated it was important to apply treatment to the whole affected area for proper wound healing. During an interview with the DON on 2/15/23 at 1459 hours, the DON verified they were behind in completing the weekly skin assessments from 12/23/22 to 2/15/23. The DON also acknowledged the medihoney treatment should be applied to the whole entire wound to ensure wound healing and stated the wounds may not heal as quickly if the treatment was not applied to the whole wound. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of 12 final sampled residents (Residents 3, 6, 10, 12, and 18) with existing pressure ulcers received the necessary treatment and services consistent with professional standards of practice. * The facility failed to consistently perform weekly wound assessments for Residents 6 and 18's pressure injuries. This put the residents at risk for poor wound healing. * The facility failed to assess and document wounds weekly for Residents 3 and 10. This failure had the potential for the residents' wounds to worsen undetected and without proper treatment and interventions. * The nursing staff failed to clean Resident 12's bowel movement before performing wound treatment and failed to complete weekly skin assessments from 12/16/22 through 2/15/23. This had the potential of Resident 12 not receiving the appropriate care and services to prevent wound infection. Findings: 555709 Page 9 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0686 Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Pressure Ulcer Prevention, Management Protocol and Treatment reviewed by the facility on 09/22, showed complete pressure ulcer assessment was to be done every seven days. 1. On 2/14/23, medical record review was initiated for Resident 6. Resident 6 was admitted on [DATE], with sacrococcyx pressure ulcer, and current wound assessment documented pressure ulcer as Stage 4. Residents Affected - Some Review of Resident 6's Short History & Physical Examination dated 7/18/22, showed Resident 6 has anoxic encephalopathy, IDDM, chronic bedridden, and spastic quadriplegia with tube feeding. Resident 6 has no capacity to understand and make decisions. Review of Resident 6's Medication Administration Record History Report dated 2/16/22, showed a physician's order to apply Honey 80% (Medihoney-used for the treatment of different types of wound including pressure ulcers) topically twice a day to Resident 6's sacrococcyx. The order also showed to cleanse the wound with normal saline, pat dry, apply collagen powder (helps with wound healing), then apply wet to dry dressing with 4x4 gauze, cover with dry dressing as needed and if soiled or dislodged. Review of Resident 6's weekly wound assessment dated [DATE], showed: the resident's wound measured 5.2 cm (length) x 7.2 cm (width) x 3.1 cm (depth), with 80% red tissue and 20% yellow slough to wound bed; whereas the wound assessment dated [DATE], showed the resident's wound measured 7 cm x 8 cm x 2.8 cm, with 50% red tissue, 40% slough, 10% eschar. Further review of Resident 6's weekly wound assessments between 12/23/22 to 2/15/23 failed to show the weekly wound assessments were performed for Resident 6's pressure ulcer on the sacrococcyx area. On 2/14/23 at 1408 hours, an interview was conducted with the DON. The DON verified the weekly wound assessments were not done to all residents with wounds after the treatment nurse left the position vacant in December 2022, and insufficient staffing did not provide opportunities for the Charge Nurses to follow up on weekly wound assessments. On 2/16/23 at 1518 hours, an interview and concurrent record review was conducted with LVN 4. LVN 4 verified the wound care order in the MAR for Resident 6's pressure ulcer was changed by the nurse practitioner and required application of Santyl ointment to the wounds; and the medihoney and collagen powder was discontinued. LVN 4 was asked why the wound treatment was changed, and she stated the wound was not healing properly. LVN 4 was asked who was she reporting to for any changes of the wound, and she stated she would report it to the charge nurses. On 2/2/23 at 1426 hours, an interview was conducted with the Risk Manager. The Risk Manager confirmed if the nurses were not doing weekly wound assessments, then it would increase the risk of worsening the pressure ulcer in size and condition because the wound assessment was used to monitor the wounds. On 2/21/23 at 1552 hours, a concurrent interview and record review was conducted with Charge Nurse 2. Charge Nurse 2 was shown a copy of the weekly wound assessments documented on 12/23/22 and 2/15/23. Charge Nurse 2 was asked why Resident 6's pressure ulcer measurements increasing and wound bed description changing. Charge Nurse 2 verified they did not have a treatment nurse to do the weekly 555709 Page 10 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0686 Level of Harm - Minimal harm or potential for actual harm pressure ulcer assessments, and they were not doing the weekly wound assessments due to staffing issues. Charge Nurse 2 was asked what was the purpose of weekly wound assessments and she stated it was to monitor the progress of the wounds. Charge Nurse 2 confirmed if the weekly wound assessments were done, it would prevent Resident 6's pressure ulcer from increasing in size and worsening of wound bed. Residents Affected - Some 555709 Page 11 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 14) and one nonsampled resident (Resident 13) were free from hazards. * The facility failed to ensure Residents 13 and 14, with a diagnosis of seizure disorders (a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness), had padded side rails to prevent injury during an episode of seizure activity. This failure had the potential for injury to Residents 13 and 14. Findings: Review of the facility's P&P titled Seizure Precautions revised and reviewed by the facilty on 6/2020 showed the side rails are to be padded with bath blankets or anti-trauma pads. The procedure is to be started on all patients with a diagnosis or history of seizure activity. 1. Medical record review for Resident 14 was initiated on 02/14/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's the Short History and Physical examination dated 7/21/22, showed diagnoses that included a seizure disorder. On 2/14/23 at 1458 hours, an observation of Resident 14 was conducted. Resident 14 was observed laying on his back in bed. Resident 14's bed side rails were up and observed without any padding. On 2/15/23 at 1033 hours, an interview and concurrent medical record was conducted with LVN 1. When asked to describe Resident 14, LVN 1 stated Resident 14 was completely dependent on staff for all care and was unable to express needs, thoughts, or feelings. When asked what precautions the facility staff should take for a resident with seizures, LVN 1 stated the resident should have padded bed side rails. When asked why the intervention was important, LVN 1 stated so the residents would not injure themselves in the event of a seizure. On 2/15/23 at 1059 hours, an observation of Resident 14 was conducted with LVN 1. Resident 14 was observed laying in bed. LVN 1 verified Resident 14 did not have padded raised side rails. When asked if Resident 14's bed should have padded side rails, LVN 1 stated yes. 2. Medical record review for Resident 13 was initiated on 02/15/23. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Long History and Physical examination dated 9/22/22, showed the resident's diagnoses included a seizure disorder. On 2/16/23 at 1148 hours, an observation of Resident 13 was conducted with RN 1. Resident 13 was observed in bed. Resident 13's bed was observed without padding of any kind on the raised side rails. RN 1 verified the above findings. RN 1 verified Resident 13's bed should have padded side rails to prevent injury and did not. 555709 Page 12 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and facility P&P review, the facility failed to ensure the necessary care and services provided related to GT for one nonsampled resident (Resident 4). Residents Affected - Few * LVN 3 did not properly check Resident 4's GT placement prior to administering the medications via GT as per the facility's P&P. This failure had the potential to cause health complications for the resident. Findings: Review of the facility's P&P titled Medication Administration Via Feeding Tube revised 8/2021 showed to check the tube placement by introducing 15-20 ml of air, using a stethoscope to auscultate. On 2/15/23 at 0830 hours, during the medications pass observation for Resident 4, the following was observed: LVN 3 administered 15 ml of air via the resident's GT and checked for placement without the use of a stethoscope (medical instrument used for detecting sounds produced in the body) when the physician's order dated on 4/24/11, showed to check the GT placement every shift and prior to administration of the feeding, water, or medications. Review of Resident 4's care plan problem to address the resident's GT showed an approach dated 2/27/18, to check the feeding tube placement and residual prior to giving the medications and feeding. On 2/15/23 at 0910 hours, during an interview with LVN 3, she stated the GT placement was checked by using a stethoscope to hear for air. LVN 3 verified she did not use a stethoscope when checking for the placement prior to administering the medications for Resident 4 and stated she forgot to use one. During an interview with the DON on 2/15/23 at 1515 hours, the DON stated a stethoscope should be used when checking for placement for the resident's GT. 555709 Page 13 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 2/13/23 at 0850 and 1000 hours, Resident 12 was observed in bed with bilateral side rails elevated. Medical record review for Resident 12 was initiated on 2/13/23. Resident 12 was admitted to the facility on [DATE]. Review of the MDS dated [DATE] , showed Resident 12 had severe cognitive impairment. Review of the Physician Order dated 8/31/21, showed an order for bilateral siderails up for involuntary muscular spasm and family request for safety. Review of the Siderail assessment dated [DATE], showed Resident 12 needed to use the side rails for safety due to high fall risk and history of seizure activity. Further review of the medical record did not show an assessment for the risk of entrapment. On 2/15/23 at 0928 hours, an interview and record review were conducted with the MDS Coordinator. The MDS Coordinator was asked if the informed consent use of the side rail was signed by the responsible party. The MDS Coordinator stated the informed consent for side rails use was not signed by the responsible party. The MDS Coordinator stated the resident was unable to express his needs or thoughts. They should obtain consent from the responsible party to be aware of the risk of entrapment and benefit for the use of the side rail. The MDS Coordinator verified the findings. On 2/16/23 at 1018 hours, an interview and concurrent medical record review were conducted with the MDS Coordinator. The MDS Coordinator confirmed Resident 12 was not assessed for the risk of entrapment prior to the installation of the bed rails. 5. On 2/13/23 at 0814 and 1118 hours, Resident 9 was observed in bed with the bilateral side rails elevated. Medical record review for Resident 9 was initiated on 2/13/23. Resident 9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE] , showed Resident 9 had severe cognitive impairment. Review of the Physician Order dated 11/23/22, showed an order for the bilateral side rails up for involuntary muscular spasm and family request for safety. Review of the Siderail assessment dated [DATE], showed Resident 12 needed to use the side rails for involuntary muscular spasm and family request for safety. Further review of the medical record did not show an assessment for the risk of entrapment or use of the bed rails for involuntary muscular spasm and safety. On 2/16/23 at 1025 hours, an interview and record review were conducted with the MDS Coordinator. 555709 Page 14 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The MDS Coordinator confirmed Resident 12 was not assessed for the risk of entrapment prior to the installation of the bed rails. Based on observation, interview, medical record review , and facility P&P review, the facility failed to ensure 10 of 12 final sampled residents (Residents 1, 4, 6, 7, 9, 12, 17, 18, 20, and 23) remained free from accident hazards due to use of elevated side rails in bed. * The facility failed to assess the risk of entrapments for Residents 1, 4, 6, 7, 9, 12, 17, 18, 20, and 23. * The facility failed to obtain the informed consents from Resident 12 and 23 prior to the use of bilateral side rails in bed. These failures had the potential to place the residents at risk for entrapment and serious injury. Findings: According to the facility's P&P titled Assessment: Siderail dated 9/22 showed each resident should be assessed for the use of siderail upon admission and an order from the physician will be obtained indicating the medical justification for use of siderail. According to the FDA, potential risks of bedrails include strangling, suffocation, serious bodily injury or death when residents or parts of their bodies are caught between rails, the openings of the rails, or between the bedrails and the mattress. Bedrails may create negative psychological effects such as contributing to resident isolation and incontinence. Those most at risk for entrapment include the frail and elderly. 1. Medical record review for Resident 17 was initiated on 2/14/23. Resident 17 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 17 needed an extensive assistance from one facility staff with bed mobility. Review of the Siderail assessment dated [DATE], showed Resident 17 needed to use side rails for mobility and repositioning. Further review of the medical record failed to show Resident 17 was assessed for the risk of entrapment related to side rail use. On 2/13/23 at 1002 hours, during the initial tour, Resident 17 was observed in bed with bilateral side rails elevated. On 2/14/23 at 1335 hours, Resident 17 was observed in bed with bilateral side rails elevated. On 2/16/23 at 0901 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 17 used the side rails for safety. CNA 6 stated Resident 17 needed assistance in repositioning and turning in bed. On 2/16/23 at 0941 hours, an interview and concurrent medical record review for Resident 17 was 555709 Page 15 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0700 Level of Harm - Minimal harm or potential for actual harm conducted with the MDS Coordinator. The MDS Coordinator verified Resident 17 used the side rails in bed. The MDS Coordinator was asked about the side rail entrapment assessment. The MDS Coordinator verified there was no entrapment assessment for the side rail use. Cross reference to F909, example #1. Residents Affected - Some 2. Medical record review for Resident 20 was initiated on 2/14/23. Resident 20 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 20 needed extensive assistance from one facility staff with bed mobility. Review of the Siderail assessment dated [DATE], showed Resident 20 needed to use side rails for safety. Further review of the medical record failed to show Resident 20 was assessed for the risk of entrapment related to side rail use. On 2/13/23 at 1449 hours during the initial tour, Resident 20 was observed in bed with bilateral side rails elevated. On 2/14/23 at 1353 hours, Resident 20 was observed in bed with bilateral side rails elevated. On 2/15/23 at 1032 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 20 used the side rails for safety. CNA 3 stated Resident 20 needed assistance in repositioning and turning in bed. On 2/16/23 at 0930 hours, an interview and concurrent medical record review for Resident 20 was conducted with LVN 7. LVN 7 verified Resident 20 used the side rails in bed. LVN 7 stated the side rails were used for safety. On 2/16/23 at 0950 hours, an interview and concurrent medical record review for Resident 20 was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 20 used the side rails in bed. The MDS Coordinator was asked about the side rails entrapment assessment. The MDS Coordinator verified there was no entrapment assessment for the side rails use. Cross reference to F909, example #2. 3. Medical record review for Resident 23 was initiated on 2/14/23. Resident 23 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 23 needed extensive assistance from two facility staff with bed mobility. Review of the Siderail assessment dated [DATE], showed Resident 23 has no medical justification for the use of side rail and side rails was not indicated. Further review of the medical record failed to show Resident 23 was assessed for risk of entrapment related to side rail use. On 2/13/23 at 1236 hours, during the initial tour, Resident 23 was observed in bed with bilateral 555709 Page 16 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0700 side rails elevated. Level of Harm - Minimal harm or potential for actual harm On 2/14/23 at 1331 hours, Resident 23 was observed in bed with bilateral side rails elevated. Residents Affected - Some On 2/15/23 at 1024 hours, an interview for Resident 23 was conducted with CNA 3. CNA 3 stated Resident 23 used the side rails to prevent the resident falling out of bed. CNA 3 stated Resident 23 had no episodes of falling out of bed. On 2/16/23 at 0958 hours, an interview and concurrent medical record review for Resident 23 was conducted with LVN 7. LVN 7 verified Resident 23 used the side rails in bed. LVN 7 stated the side rails were used for safety and per family request. LVN 7 stated Resident 23 was not able to move or reposition herself in bed. On 2/16/23 at 1005 hours, an interview and concurrent medical record review for Resident 23 was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 23 used the side rails in bed. The MDS Coordinator verified there was no documented evidence an informed consent for the use of the side rails was obtained. The MDS Coordinator was asked about the side rails entrapment assessment. The MDS Coordinator verified there was no entrapment assessment for the side rails use. Cross reference to F909, example #3. On 2/21/23 at 1429 hours, an interview and concurrent medical record review for Residents 17, 20, and 23 was conducted with the DON. The DON informed and verified the above findings. 6. On 2/13/23 at 0945 hours, during initial rounds, Residents 4 and 18 were observed in bed with bilateral side rails up. Resident 4 had padded side rails. On 2/13/23 at 0958 hours, during an initial round, Resident 1 also observed in bed with bilateral side rails up. On 2/21/23 at 0838 hours, during an interview with CNA 2 who was assigned to Residents 1, 4, and 18, CNA 2 stated all three residents were unable to independently get out of bed and needed to be assisted by the staff with repositioning. CNA 2 verified the side rails were up at all times for the three residents. On 2/21/23 at 0843 hours, review of the medical records for Residents 1, 4, and 18, showed the following: - Resident 1 was admitted to the facility on [DATE]. - Resident 4 was admitted to the facility on [DATE]. - Resident 18 was admitted to the facility on [DATE]. Further review of the medical records showed no documented evidence of the risk for entrapment assessments for these residents. On 2/21/23 at 0856 hours, an interview with the Risk Manager was conducted. The Risk Manager stated many of the residents did not have the functional mobility to get out of bed. 555709 Page 17 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/21/23 at 1355 hours, during a follow up interview with the Risk Manager, he verified the DON or MDS could not provide the Risk for Entrapment Assessment form. The Risk Manager further stated assessing for the entrapment was important to avoid the risk of injury if the resident became entangled between the zones of the bed. On 2/23/23 at 1420 hours, an interview with RN 2 was conducted. RN 2 verified the facility did not do the entrapment assessments. RN 2 stated the entrapment assessments was to ensure the appropriateness of side rails for the resident, and stated entrapment may cause injury to the resident. 7. Medical record review for Resident 6 was initiated on 2/13/23. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's history and physical examination creation dated 7/18/22, showed Resident 6 had anoxic encephalopathy, spastic quadriplegia, and was chronic bedridden. Further review of Resident 6's medical record showed the completed side rail assessment and signed consent for the use of the side rails, however, there was no documented evidence of the entrapment assessment. On 2/13/23 at 1030 hours, an observation and concurrent interview was conducted with CNA 5. Resident 6 was observed with the bilateral side rails up on bed, which was verified by CNA 5. CNA 5 was asked if Resident 6 was using the side rails and what the purpose of the side rails was. CNA 5 stated Resident 6 did not move nor used the side rails. CNA 5 stated the purpose of the side rails was to prevent Resident 6 from falling. 8. On 2/14/23 at 0841 hours, observation and interview was conducted with LVN 6. During the initial tour, Resident 7 was observed with the bilateral side rails up while in bed, which was verified by LVN 6. LVN 6 was asked if Resident 7 used the side rails and she stated Resident 7 did not use it, but the side rails was used to prevent him from falling off the bed. Medical record review for Resident 7 was initiated on 2/14/23. Resident 7 was admitted to the facility on [DATE]. Further review of Resident 7's medical record showed the resident was in a chronic vegetative state and had the completed side rail assessment and signed consent form for the use side rails. However, there was no documented evidence of the entrapment assessment. On 2/21/23 at 0940 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator verified the facility had implemented and utilized the side rail assessments forms only and no entrapment assessment. On 2/21/23 at 1420 hours, an interview was conducted with RN 2. RN 2 verified they conducted the side rail assessment, not entrapment assessment. RN 2 also confirmed it was important to conduct an entrapment assessment to ensure the appropriateness of the side rails. 555709 Page 18 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 17 and 20) were free from unnecessary psychotropic medications. * Resident 17 had the physician's order for Xanax (medication for anxiety). The facility failed to ensure Resident 17's use of Xanax had a specific behavior manifestation for the provision of psychotropic medication use. The facility also failed to ensure Resident 17's use of Xanax had a stop date and the justification for continuing use of the medication. Furthermore, the facility failed to ensure Resident 17's consent for use of Xanax medication was revised when the medication dosage was increased. This posed a risk of Resident 17 to not be informed regarding the medications and Residents 17's physician not having the necessary information to determine the effectiveness of the medication. * Resident 20 had a physician's order for Klonopin (medication for anxiety). The facility failed to ensure to monitor for a specific behavior manifestation related to the use of the medication. This failure has the potential for inaccurate behavior monitoring and Resident 20's physician not having the necessary information to determine the effectiveness of the medication. Findings: 1. Medical record review for Resident 17 was initiated on 2/14/23. Resident 17 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 17 was cognitively intact. a. Review of Resident 17's Medication Administration Record for the month of February 2023 showed an order dated 9/24/22, to administer Xanax 0.5 mg by GT every eight hours as needed for anxiety agitation. However, there was no documentation of the manifestation of the behavior being monitored for the use of Xanax. In addition, there was no stop date for the use of the Xanax medication for as needed use and there was no documentation for the justification for the prolong use of the medication was documented. b. Furthermore, review of Resident 17's informed consent for the use of Xanax medication dated 7/29/22, showed the dose of the Xanax medication was 0.25 mg. There was no informed consent obtained from Resident 17 for the use of Xanax 0.5 mg dose. Review of the Medication Regimen Review for Resident 17 completed by the pharmacist dated 1/24/23, showed there was no recommendation necessary. On 02/21/23 at 1019 hours, an interview and concurrent medical record review for Resident 17 was conducted with the Pharmacist. The Pharmacist verified the physician's order for Resident 17's use of medication Xanax. The Pharmacist verified the above findings. The Pharmacist stated there should have been a behavior manifestation being monitored, a stop date and justification for the use of the medication, and consent when the dose of the medication was increased. 555709 Page 19 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Medical record review for Resident 20 was initiated on 2/14/23. Resident 20 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 20 was cognitively impaired. Review of the Medication Administration Record for February 2023 showed a physicians order dated 9/13/21, to administer Klonopin 0.25 mg by GT twice a day for tremors. Further review of the medical record failed to show documentation of the specific behavior manifestation for the use of Klonopin. Review of the Medication Regimen Review for Resident 20 completed by the Pharmacist dated 1/17/23, showed no recommendation necessary and was signed by the physician. On 02/21/23 at 1041 hours, an interview and concurrent medical record review for Resident 20 was conducted with the Pharmacist. The Pharmacist verified the above findings. The Pharmacist stated there should have been a manifestation behavior for the use of the Klonopin medication. On 2/21/23 at 1451 hours, an interview and concurrent medical record review for Residents 17 and 20 was conducted with the DON. The DON informed and verified the findings. 555709 Page 20 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was less than 5%. Residents Affected - Few * The facility's med error rate was 32.14%. One of two licensed nurses (LVN 2) was found to have made errors during the medication administration to one of 12 final sampled residents (Resident 6). This failure had the potential to negatively affect the residents' well-being. Findings: Review of the facility's P&P titled Medication Administration Via Feeding Tube revised August 2021 showed the procedure for medication administration included the pills, tablets or empty contents of the capsules in separate containers and mixing with water. On 2/15/23 at 0833 hours, an observation of medication administration via GT was conducted with LVN 2. LVN 2 was observed crushing nine tablets, which consisted of the following medications: - hyrdalazine (antihypertensive) 25 mg one tablet - vitamin D3 (supplement) 25 mcg one tablet - Losartan Potassium (antihypertensive) 25 mg tablet - glipizide (antidiabetic) 5 mg one tablet times two (total of two tablets) - Tradjenta (antidiabetic) 5 mg one tablet - levetiracetam (anticonvulsant) 500 mg one tablet - hydrocodone (Bitartrate 10 mg/acetaminophen 325 mg) (narcotic analgesic) one tablet - folic acid (supplement) 1 mg one tablet - nephro-vite (supplement) one tablet LVN 2 placed all crushed tablets together in one medicine cup, opened one capsule of Culturelle 15 billions CFUS into one medicine cup, and opened one packet Juven nutritional powder supplement into a standard up. LVN 2 proceeded with entering Resident 6's room, identified Resident 6 using appropriate identifier, held the continuous feeding, checked GT placement using a stethoscope, and administered the medicine cup of nine crushed tablets mixed with water first, then followed by flushing the remaining two individual cup of medicines. On 2/14/23 at 1441 hours, an interview and concurrent facility P&P review was conducted with LVN 2. The observation and review of the facility's P&P on medication administration were verified with LVN 2 that each of the nine tablets of medication was to be placed in a separate cup. LVN 2 stated she should not be mixing multiple crushed medications into one container. When asked what the purpose of separating the medicines into different cups was, LVN 2 stated to monitor for the resident's medication adverse reactions. LVN 2 confirmed she might not be able to distinguish the mixed crushed 555709 Page 21 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0759 medications if she had spilled the medicine cup. Level of Harm - Minimal harm or potential for actual harm On 2/16/23 at 1538 hours, an interview was conducted with the DSD. The DSD verified the facility's policy for medication administration for GT that each crushed medicine was to be placed in a separate medicine cup and administered each medication individually via GT. The DSD confirmed the purpose of separating each crushed medicine was to monitor for adverse reactions. Mixing the crushed medicines together in a single cup and administered together at the same time would inhibit the ability to distinguish which medicine had caused the adverse reactions. Residents Affected - Few 555709 Page 22 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 3. On 2/15/23 at 0825 hours, an observation of the medication storage was conducted with RN 2. Nine breathing treatment medications were observed in a blue container labeled pharmacy on top of the medication refrigerator. RN 2 verified the above medications were not locked up and should have been. When asked to elaborate, RN 2 stated they were medications and not supposed to be out. They were unlocked and should be locked in the drawer. 2. Review of the facility's P&P titled Medication Storage and Securit reviewed date 06/20 showed all medications shall be stored in appropriately segregated and secure conditions to minimize the potential for medication errors and theft or diversion. During a concurrent observation of Resdient 1's room and interview with LVN 3 on 2/13/23 at 0958 hours, four medication cups with liquid medication and one medication cup with crushed medication were observed unattended at Resident 1's bedside. LVN 3 verified the liquid medications in the individual medication cups were left unattended included liquid iron (supplement), liquid potassium (supplement), liquid colace (stool softener), and miralax. LVN 3 further stated she crushed and combined the following medications in one medication cup: multivitamin (supplement), vitamin D (supplement), magnesium (supplement), and zinc tablets (supplements). LVN 3 stated she was going to administer the medications to Resident 1 but had to assist Resident 1's roommate in B bed with a suction (clearing the airway of saliva or other secretions) first. On 2/13/23 at 1143 hours, during an interview with LVN 3 at the nurse's station, LVN 3 acknowledged she was supposed to give the medications one by one. LVN 3 further stated the facility's policy was to place each medication into a separate medication cup. LVN 3 stated it was important to separate each medication to ensure no reaction was observed and the resident took all the medications. On 2/21/23 at 0903 hours, an interview with the Risk Manager was conducted. The Risk Manager stated the medications were not to be left unattended and should be within direct view. The Risk Manager further stated leaving the medications at the bedside unattended may pose a risk for ambulatory patients, family members, or staff taking or using the medication. Based on observation, interview, and medical record review, the facility failed to ensure all medications were stored securely. * One of two medication carts (Medication Cart #2) had the internal and external medications stored together. * Resident 1's medicaitons were left unattended at the bedside. * The facility failed to ensure the medications were properly stored in a locked area. These failures had the potential for medication errors and diversion. Findings: Review of the facility's P&P tilted Medication Storage and Security showed all medicines shall be 555709 Page 23 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0761 stored in an appropriately segrated condition to prevent the potential for medication errors. Level of Harm - Minimal harm or potential for actual harm 1. On 2/15/23 at 0930 hours, an observation of Medication Cart #2 and concurrent interview was conducted with LVN 1. The bottom drawer of Medication Cart #2 was divided in two separate bins and contained the following: Residents Affected - Few * In the first bin: - one container of protein powder - one container of fiber powder, resident-specific - two bottles of chlorhexidine (also known as CHG, used to reduce bacteria in the mouth) oral rinse - one container of purple Super Sani-Cloth wipes (a disposable disinfectant used on aborad range of surfaces and equipment in healthcare). * In the second bin: - eight bottles of chg oral rinse - one can of air freshener - two small bottles of blue oral rinse - one bottle of Dynahex chlorhexidne body wash - one bottle of medicated shampoo - one bottle of oral throat spray LVN 1 verified the above findings. LVN 1 was asked if the oral medicated rinse and oral throat spray should be stored together with the body wash, shampoo, and air freshener. LVN 1 stated they should not be stored or mixed up together. 555709 Page 24 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify the physician of the laboratory test results which were out of range for one of 12 final sampled residents (Resident 14). This failure had the potential for Resident 14 not receiving the therapeutic dose of medication to prevent seizures. Findings: Review of the facility's P&P titled Patient Care Guidelines revised 10/2014 showed the following: - Nursing personal should follow established guidelines in the delivering of patient care. - Notify attending and physician in charge immediately of any abnormal diagnostic finding or labs and follow up on the physician's orders if applicable. Review of Resident 14's medical record was initiated on 2/14/23. Resident 14 was admitted to the facility on [DATE]. Review of the H&P examination dated 7/21/22, showed a diagnosis of seizure disorder. Review of the MDS dated [DATE], showed the resident had seizure disorder and traumatic brain injury On 2/15/23 at 1509 hours, concurrent interview and medical record review of Resident 14 was conducted with RN 2. Resident 14's physician order summary dated 2/7/23, showed Resident 14 had a physician's order for valproic Acid (anticonvulsant medication) 250 mg/ml via feeding tube daily. Resident 14's Valproic Acid level laboratory test result showed the following: * Laboratory result dated 2/8/23, showed the resident's Valproic Acid level was <10 ug/ml. * Laboratory result dated 11/2/22 showed Valproic Acid level result was 11 ug/ml. * Laboratory result dated 8/11/22 showed Valproic Acid level result was 14 ug/ml. * Laboratory result dated 5/4/22 showed Valproic Acid level result was 12 ug/ml. * Laboratory result dated 2/2/22 showed Valproic Acid level result was 10 ug/ml. *Laboratory result dated 10/6/21 showed Valproic Acid level result was 11 ug/ml. *Laboratory result dated 9/8/21 showed Valproic Acid level result was 19 ug/ml. The laboratory results also showed the therapeutic reference range of the Valproic Acid level should be 50-125 ug/ml. All of the above laboratory results showed with a yellow explanation mark indicated in the EMAR. RN 2 verified the above laboratory results. When asked if the physician had been notified of the 555709 Page 25 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0773 Level of Harm - Minimal harm or potential for actual harm above laboratory results, RN 2 stated no. When asked what the significance of the yellow exclamation mark next to the above laboratory results, RN 2 stated that meant the laboratory results were out of range. When asked to describe the process for the staff to take when the laboratory results were out of range, RN 2 stated the staff needed to notify the physician. When asked what would be the risk for the laboratory results not being at the therapeutic levels, RN 2 stated possible seizures as the risk to Resident 14. Residents Affected - Few 555709 Page 26 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: Residents Affected - Few * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure the damaged or worn-out kitchen equipment was replaced. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Condition of Residents completed by the facility dated 2/13/23, showed four of 23 residents in the facility received foods prepared in the kitchen. 1. According to the FDA Food Code 2017, Section 3-501.17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. During the initial kitchen tour on 2/13/23 at 0820 hours, a marinara sauce in a sauce pan covered with a plastic wrap with a date of 2/7/23. The DSS was asked how long they could to keep the sauce in the refrigerator, the DSS checked the Guidelines for food storage and stated for all opened sauce in the refrigerator, they should be keep for three to five days. The DSS verified the marinara sauce had expired and stated it should have been thrown out. 2. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be: smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. On 2/15/23 at 0923 hours, an observation and concurrent interview was conducted with the DSS. The DSS was observed using the cutting board with extensive rough cut marks over most of the surface with black stains. The DSS verified the chopping board was marred and needed to be replaced. On 2/16/23 at 0936 hours, an interview was conducted with the RD. The RD was informed and verified of the above findings. The RD stated the expired foods should have been discarded and the marred chopping board should have been replaced. 555709 Page 27 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, and facility P&P review, the facility failed to conduct the regular inspections of all resident bed frames and mattresses as part of a regular maintenance program to identify areas of possible entrapment. This had the potential to place the residents at risk for entrapment and injury. Findings: According to the Food and Drug Administration (FDA) documents entitled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10. 2006, Practice Hospital Bed Safety dated February 2013, and Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, to the proper dimensions and distances apart of various parts of the bed such as distance between bed frames and mattresses, bed rails and mattress etc. to prevent entrapment by users of the bed. 1. On 2/13/23 at 1002 hours, during the initial tour, Resident 17 was observed in bed with bilateral side rails elevated. On 2/16/23 at 0901 hours, an interview for Resident 17 was conducted with CNA 6. CNA 6 stated Resident 17 used the side rails for safety. CNA 6 stated Resident 17 needed assistance in repositioning and turning in bed. 2. On 2/13/23 at 1449 hours, during the initial tour, Resident 20 was observed in bed with bilateral side rails elevated. On 2/15/23 at 1032 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 20 used the side rails for safety. CNA 3 stated Resident 20 needed assistance in repositioning and turning in bed. 3. On 2/13/23 at 1236 hours, during the initial tour, Resident 23 was observed in bed with bilateral side rails elevated. On 2/15/23 at 1024 hours, an interview for Resident 23 was conducted with CNA 3. CNA 3 stated Resident 23 used the side rails to prevent the resident falling out of bed. CNA 3 stated Resident 23 has no episodes of falling out of bed. On 2/16/23 at 1447 hours, an interview was conducted with the Director of Facilities. The Director of Facilities stated the annual inspection of the beds were conducted and was able to show the worksheet for the bed inspections. When asked if the bed entrapment inspection was completed for all the bed in the subacute unit, the Director of Facilities stated they did not complete the entrapment assessment of the beds because the beds were new and they did the entrapment assessment only for the old bed. When asked who was responsible for inspection of the side rails and perform the entrapment assessment, the Director of Facilities stated the nursing staff were responsible to do the side rails inspection and bed entrapment assessment. The Director of Facilities verified the entrapment assessments of the beds and inspection of the side rails were not done. On 2/21/23 at 1451 hours, an interview was conducted with the DON. The DON informed of the above 555709 Page 28 of 29 555709 02/21/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0909 findings and verified there were no entrapment assessments for the residents' beds. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555709 Page 29 of 29